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The Geopolitics of Ebola and Global Health Security: Why Anthropology Matters.

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Abstract

The combination of an exceptionalised disease, fragile health systems and a failure of global health leadership and governance constituted a perfect storm for the spread of Ebola in West Africa. In this heightened sense of emergency, a shift in global health securitization has occurred, which should not go unnoticed or unchallenged. Globally mediated epidemics are highly political and anthropologists are uniquely placed to interrogate the geopolitics of Ebola and global health security.
Irish Journal of Anthropology Vol. 18(1) 2015 Spring/Summer
9
COMMENT ON
THE GEOPOLITICS OF EBOLA AND GLOBAL HEALTH SECURITY: WHY ANTHROPOLOGY MATTERS
BY FIONA LARKAN*, CAROLINE RYAN, SEBASTIAN KEVANY
Introduction
The combination of an exceptionalised disease,
fragile health systems and a failure of global
health leadership and governance constituted a
perfect storm for the spread of Ebola in West
Africa. In this heightened sense of emergency, a
shift in global health securitizationi has occurred,
which should not go unnoticed or unchallenged.
Globally mediated epidemics are highly political
and anthropologists are uniquely placed to
interrogate the geopolitics of Ebola and global
health security.
The outbreak of Ebola in three West African
countries has raised the worldwide profile of this
zoonotic infectious disease to an unparalleled
level. No previous Ebola outbreak spread so
widely; the previous 24 epidemics remained
within national borders and were never reported
to have killed more than 300 people (Lancet Ebola
Resource Centre, 2014). International responses
to the West African Ebola outbreak have elicited a
wide range of responses not all positive, some
openly critical and much hyperbole.
Only 3% of World Health Organisation (WHO) non-
support staff have the non-medical skills (e.g. law,
diplomacy, trade, economics and anthropology)
required for epidemic preparedness (Gostin &
Friedman, 2015). Clearly anthropology can
contribute to understanding outbreaks in terms of
customs and practices and local responses to
disease (Hewlett & Amola, 2003; Hewlett &
Hewlett, 2007). Following a One-Health approach,
anthropologists have also explored the extent to
which human-animal-environment interactions
(Brown & Kelly 2015) and hunting practices (Wolfe
et al, 2000; Saez et al, 2014) are central to the
emergence of zoonotic diseases. Indeed because
of this, anthropology also has a significant role to
play in reviewing and critiquing the repercussions
of Ebola on international politics and international
relations.
The Perfect Storm
Exceptionalisation of Ebola
The framing of a disease as exceptional or unique
from other diseases (and therefore warranting
exceptional response) has vast, often problematic,
consequences. As evidenced by AIDS
exceptionalism, 30 years of targeted interventions
has been criticised for shifting resources
disproportionally away from endemic diseases and
health system strengthening (Smith & Whiteside,
2010), and for contributing to the problem of
stigma and self-stigma (Cameron 2006, Kelly 2006)
in low income contexts. Infectious diseases (widely
referred to as ‘emerging infectious diseases’), and
include the inappropriately named haemorrhagic
viruses, such as Ebola. The haemorrhagic term
stems from a westernized, media-hyped image
surrounding the gastro-intestinal heamorrhagic
Irish Journal of Anthropology Vol. 18(1) 2015 Spring/Summer
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clinical symptoms, sometimes seen towards the
late stages of the disease. However the more apt
and recently applied title, Ebola Virus Disease
(EVD) has not normalized the exceptional image of
Ebola. Portrayed as an uncontrollable threat,
particularly to the westernized nations, EVD is
viewed as one of the greatest threats to global
security warranting co-ordinated global action
(Kalra et al, 2014). In 2015 that global action took
the form of military deployment by donor
countries in West Africa.
Bass (1998), Bennett & Edelman (1985) Sontag
(1989) and Wald (2008) have all documented the
consequences of consistent and stereotypically
negative narratives of a disease. By fashioning an
account around a priori assumptions,
‘history seems clear and undeniable because the
analytical perspective has made it so […] leaving the
psychological impression that one is experiencing
reality-driven objectivity’ (Bennett & Edelman,
1985:162).
Sontag (1989:141) observed that ‘from class
fiction to the latest journalism, the standard
plague story is of inexorability, inescapability’.
Bass (1998:446) argues that this ‘hegemonic
residue of imperial 'contamination' remains
embedded in our culture’.
Thus, along with a ‘disease-knows-no-borders’
rhetoric, this move toward securitised response
strategies has emerged from a concept of
‘universal consensus’. Granted, the concept of
universality in terms of collaboration and sharing
resources to resolve major global challenges is
hard to challenge. However targeting responses to
Ebola from the perspective of containment in
terms of securitization, and placing such response
strategies at the top of the global health agenda,
may support a ‘universal consensus’ that in
Connell’s (2007) words represents ‘the views of
the most privileged 600 million assuming the same
views are experienced by the whole 6000 million
who are actually in the world’.
Fragile Health Systems:
The high mortality from Ebola in this instance is in
part due to inadequate health systems and lack of
resources (Boozary, Farmer & Jha, 2014)-
problems that will continue to challenge these
three West African governments when the
outbreak is contained. Edelstein, Anglides &
Heymann, (2015) detail some of the challenges
that are already being observed - decreased
vaccination coverage for infectious diseases
(including measles); a disruption to HIV, TB and
Malaria programmes, and the loss of more than
800 health workers from an already depleted
health workforce. The focus on Ebola at the
expense of other health programmes has resulted
in an increase in the rates of other treatable
diseases including respiratory viruses, diarrhoea,
Lassa fever, malaria (Lancet Ebola Resource
Centre, 2014). And this does not begin to explore
the economic, social, and psychological impact of
the outbreak which will also have repercussions
for many years to come.
Failure of Global Health Leadership and
Governance
It is clear that global health leadership failed West
Africa in this instance (Farrar & Piot 2014, Gostin
& Friedman 2014, 2015, Horton, 2015, Rosling
2015, Boozary et al 2014). The early response was
left to national governments of the three most
affected countries Sierra Leone, Guinea and
Liberia which are amongst the world’s lowest
ranking countries in terms of the Human
Development Indexii; none had the capacity or
infrastructure to respond to the worsening crisis.
Irish Journal of Anthropology Vol. 18(1) 2015 Spring/Summer
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The WHO over the past decade has reduced its
core budget, and the bulk of its remaining budget
is project/programme driven, with relatively little
core budget to respond quickly to situations such
as Ebola (Rosling 2015). Despite the
establishment by the WHO in 2005, of a legally
binding governing legal framework the
International Health Regulations there is no
coordinated, funded commitment to countries
with reduced capacity to comply with the
regulations (Wilson, Brownstein & Fidler, 2010).
Global health governance is shown to be an ‘ad
hoc series of institutions, laws and strategies that
do not function as a coherent whole’ (Gostin &
Friedman 2015:1903). In the vacuum created by
the lack of clear leadership we saw a shift in
power from the WHO to the UN in the form of a
UN Mission (UN Mission for Ebola Emergency
Response UNMEER) which, as Boozary et al
(2014) point out, gained more support than any
resolution since the founding of the United
Nations in 1946.
Global Health Security
The West African Ebola outbreak, constituted a
serious crisis for the people of West Africa, not for
the world. It was without doubt a humanitarian
emergency that merited international support and
assistance. However the securitization and
militarization that followed should not go
unnoticed or unchallenged.
While the idea of Global Health ‘security’ has been
in existence for some time, in recent years this has
increasingly been shaped by the war on terror
(Collier et al, 2004). Ingram (2005) explores the
origin of the structure and dynamics of the
security discourse, and its shift from the
paradigmatic case of war. Extending the security
discourse to other realms he argues, ‘risks mis-
stating the nature of the problem, rendering
'security' analytically fuzzy, or calling forth
inappropriate state involvement’ (2005: 524).
Global health security thus becomes
extraordinary, or outside the frame of ‘normal
politics’. The decision to introduce forces (in a civil
defence capacity) might seem attractive, even
understandable, advantages include the
productive and humanitarian employment of
personnel and equipment otherwise designed for
destructive purposes and the increased
integration between international development
and broader international affairs and relations
under the ‘smart global health’ (CSIS, n.d.)
paradigm. However, the ‘norm of preparedness’
(Lakoff, 2008) which shapes, and structures, the
Emergency Response discourse and strategies has
ongoing consequences for global health and
involves ‘the migration of techniques initially
developed in the military and civil defense to
other areas of governmental intervention’
(2008:422). The concern here is while the key to
preparedness would undoubtedly be a robust
health system in each country, that goal is being
usurped by preparedness for an ‘emergency
response’. The best possible form of preparedness
would be a combination of long-term, well
resourced health systems in-country and strong
global health governance structure.iii
Of particular concern is the manner in which
donor countries, such as the United States and
European Union member states (including the
Republic of Ireland), dispatched military forces on
the basis of an ‘emergency response’ – on the
basis that armed forces are considered to have the
most well-developed capacity to respond to
epidemic outbreaks that threaten health security
in a way that the more lumbering, bureaucratic
structures of the United Nations and other
supranational and multilateral organizations could
never hope to do.
Irish Journal of Anthropology Vol. 18(1) 2015 Spring/Summer
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This interface between societal, political and
medical forces is where anthropology should
situate itself. How have recipient and other
severely-affected societies been affected by the
international response? To what extent have
issues of national sovereignty and independence
been jeopardized by the occupation of
international armed forces in West Africa? How
are legislative, diplomatic and organizational
structures developed and maintained often at
very short notice to govern such measures?
How are local communities affected? And,
perhaps most importantly, what precedent does
this set on an international level? Could the
incumbent Russian government, for example,
employ similar measures on the basis of national
security in response to perceived or actual
disease outbreaks in the Ukraine?
In the 21st Century, security concerns including
specific elements such as global health security
tend to trump all other considerations, including
the diplomatic, the societal, the medical, the
political and (given the costs of securitization) the
economic. Similarly, at the individual, community
and national population levels, these concerns
may have eroded other priorities. The gains are
manifold; including diversification of military roles,
greater resource allocation to global health, and
tangible increases in human security. But what are
the costs, most particularly at the societal and
cultural levels? The imposition of global health
security measures, including surveillance, the
employment of health service provision from
outside the national health system without an
official mandate, and the associated
disempowerment of the individual in related
policy decisions all stand to erode social and
political empowerment in developing countries.
In order for future interventions comparable to
the Ebola response to be successful, the
employment of anthropological perspectives and
preparations are therefore essential.
Conclusion
The combination of disease exceptionalism, fragile
health systems and a failure of global health
governance has contributed to a shift in power in
global health emergency responses, and the
setting of unfortunate precedents. The overlap
between military forces and global health
initiatives is not limited, as one might imagine, to
global ‘superpowers’. In conjunction with the
global response, the Irish Department of Defence
deployed 4 personnel to the United Kingdom’s
Ebola treatment centre in Sierra Leone in 2015.
Although the recent involvement of the Irish Navy
in the European migrant crisis does not transgress
international sovereign borders, these efforts
provide a further compelling example of the
armed forces’ enhanced role in health and
humanitarian endeavors with a specific focus on
emergency responses in the 21st Century.
For better or for worse, the precedent has been
set for the militarization of such interventions.
The question that both the global health and
anthropological communities will face is whether
to embrace or steadfastly oppose these changing
remits and purviews. If the former, the
articulation of a set of standards or guidelines,
jointly developed by civil society, the military, and
the global health community, governing the
boundaries of military involvement in global
health efforts according to diplomatic’ standards,
should be articulated. It is not enough for Western
powers to mobilize responses to resource poor
settings and withdraw once the crisis is overcome.
Failure to build up strong health systems will
inevitably lead to additional crises in the future,
and require further rapid (and costly) intervention
Irish Journal of Anthropology Vol. 18(1) 2015 Spring/Summer
13
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Notes
i The process of (in this case) supranational and
international actors transforming subjects into matters of
‘security’, thus enabling extraordinary means to be used in
the name of security.
ii United Nations Human Development Index ranks Sierra
Leone, Guinea, and Liberia at 183rd, 179th and 175th
respectively on a scale of 187 (UNDP, 2013)
iii One of the few good reviews the US military received in
this regard was the construction of long-term health clinics
however these are often un-used because of parameters
on treatment.
The West African Ebola Viral Disease (EVD) situation:
As of 12th August 2015 WHO reports 27,929 total cases (Suspected, Probable, and
Confirmed) of this strain of Ebola subtype ZEBV (CDC 2014, Baize et al 2014, Kalra et
al 2014), with total deaths recorded as 11,283. Guinea and Sierra Leone continue to
have new cases though the trend is downward. Liberia, has been declared Ebola-free.
The WHO situation report of 10th June 2015 states 'case incidence has been below 10
confirmed cases per week for three consecutive weeks, but there remains a significant
risk of further transmission and an increase in case incidence in the near and medium
term'.
World health Organisation (2015). Ebola Situation Report 12th August 2015. WHO, Geneva
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At the core of the present Ebola crisis in West Africa is a lack of global health leadership. WHO should be the global health leader, following its constitutional charge, yet it is significantly under-resourced, having a direct effect on its rapid response capacity. The Organization's response to this crisis has been constantly behind, from low funding appeals to its delay in declaring this outbreak to be a Public Health Emergency of International Concern under the binding International Health Regulations (2005) (IHR). The IHR themselves have proven insufficient, as countries have failed to cooperate in building the public health capacities that the IHR requires, reflecting the absence of incentives, sanctions, or a clear allocation of responsibility.The United States and United Nations have sought to fill this leadership vacuum. The United States is deploying military assets to utilize their logistics, engineering, and similar capacities. Yet a single state cannot fill the significant governance gaps, mobilizing and coordinating global efforts. The United Nations has now assumed this leadership role. The UN Security Council's resolution has raised the political profile in a way that WHO could not even as the resolution left unclear the exact duties required of states. The UN Secretary-General initiated the UN Mission for Ebola Emergency Response.Going forward, the United Nations must maintain its leadership, from the Security-General identifying states that fail to contribute fairly to the global response -- or that strip other health and development funding to do so -- to the Security Council being prepared to pass another resolution, this one with unambiguous binding authority and clear allocation of responsibility. Looking further ahead, the Security Council should interpret its mandate for maintaining international peace and security broadly, encompassing human security. States should give WHO the funding and other support the Organization requires, as WHO undertakes reforms necessary for it to be a global health leader. The UN Secretary-General and WHO Director-General should establish an independent commission to comprehensively review the response and recommend what is needed to prevent future global health emergencies. National and institutional leaders must respond to Ebola by enacting the far-reaching reforms required for genuine global health leadership, exercising the political will and leadership whose absence enabled the current Ebola outbreak to turn into a global crisis.
Article
The 25th known outbreak of Ebola virus infection is unlike any of the previous epidemics. It has already killed over 2800 people - more than all previous epidemics combined; it's affecting virtually the entire territory of three countries, involving rural areas, major urban centers, and capital cities; it has been going on for almost a year; and it is occurring in West Africa, where no Ebola outbreak had previously occurred. Above all, the epidemic seems out of control and has evolved into a major humanitarian crisis that has finally mobilized the world, with responses ranging from an emergency health mission . . .